“At a time like this, scorching irony, not convincing argument, is needed.”
- Frederick Douglass
In an accompanying “The Open Mind” article, Prielipp et al.1 thoughtfully describe the positive impact of changes made by the specialty of anesthesiology during the past several decades as its leaders and practitioners have proactively and carefully created and supported its gradual, step-by-step evolution to include the breadth and depth of perioperative medicine. For the purposes of this article, perioperative medicine is inclusive of periprocedural medicine. Anesthesiologists now play important clinical and administrative roles both within and outside of traditional operating room and interventional medicine settings. However, the authors start their discussion by suggesting that anesthesiology is confronted by a burning platform that apparently requires immediate action to change the specialty as we currently know it and paradoxically end their discussion by quoting Jack Welch, former Chairman and CEO of General Electric, “Change before you have to.”
This conflicting commentary is, indeed, ironic. Change is exactly what anesthesiologists have been doing. Recall that anesthesiology leaders pursued new opportunities in clinical practice for decades, especially through the development of critical care and pain medicine subspecialties. However, in the late 1990s, a downturn in young physicians choosing anesthesiology as a specialty in the United States led, in part, to a retrenchment of anesthesiologists into traditional operating room settings and a dramatic reduction in the number of men and women in the specialty seeking training beyond clinical intraoperative anesthesia. The influence of anesthesiologists in discussions about the management and evolution of health systems, hospitals, and national health policies was at risk as fewer anesthesiologists were available to participate in clinical care outside of nonoperative settings or in health care administrative leadership roles; furthermore, those who were available to participate in such discussions were typically devoid of the specialized education and experiences necessary to contribute in a meaningful manner. Concern about this risk triggered specialty leaders from the American Society of Anesthesiologists (ASA), American Board of Anesthesiology (ABA), and Anesthesiology Review Committee of the Accreditation Council of Graduate Medical Education (ACGME) to specifically seek changes that might re-expand anesthesiology clinical practices and re-engage anesthesiologists in broader participation in many areas of medicine and health care administration. These groups and other anesthesiologists have spent the most recent 14 years pursuing a strategic expansion of the field of anesthesiology to encompass far more than traditional intraoperative care. Mr. Welch’s admonition to change is exactly what the specialty has been doing.
From soon after the initial October 2000 meeting of ASA, ABA, and ACGME leaders during the ASA annual meeting in San Francisco that led to the creation of the Council on the Continuous Professional Development of Anesthesiologists and set the march toward what became known as the Perioperative Surgical Home® (PSH) concept in 2011, literally thousands of anesthesiologists in both academic and private practices, large and small, as well as leaders from organizations representing surgical and procedural fields, nursing, and hospital administration, have provided input into the proposed idea that anesthesiologists could and should play a broader role in perioperative care. Leaders of federal or national regulatory agencies such as the Centers for Medicare and Medicaid Services and The Joint Commission, respectively, have also offered their insights. Prielipp et al.,1 several of which authors themselves have been very involved during the past decade in discussions about the future of the specialty and the development of the PSH concept, have now decided that these efforts have not been sufficient. Although a number of ideas noted in their accompanying article are controversial, several in particular deserve comment.
A BURNING PLATFORM?
Prielipp et al.1 imply that there is a burning platform requiring prompt action and that anesthesiology is at a crossroads. On the contrary, anesthesiology as a medical specialty is very healthy and strong in the United States at this time. As noted by Richard P. Dutton, MD, Executive Director of the Anesthesia Quality Institute, when commenting on the specialty as practiced currently in the United States, involuntary unemployment of anesthesiologists, absent substance abuse or another health issue, is nearly nonexistent. Anesthesiologists continue to be highly compensated, and the specialty currently attracts outstanding medical school graduates. Patient safety, especially related to intraoperative care, is as good as it has ever been. The demand for anesthesia services, including those outside of traditional operating rooms, is challenging our ability to meet it. Thus, it seems particularly appropriate for the specialty to now “change before it has to” and while in a position of strength. Inherent in that approach is the wonderful advantage of making slow and deliberate changes, measuring their outcomes before pushing them forward further and faster.
That is exactly the approach taken by the ASA with its PSH Collaborative in which a large number of diverse practices are developing and testing various models of the PSH and, in the near future, begin to share their results and best practices with others. Pediatrics and internal and family medicine in the United States have undertaken similar efforts during the past several decades to improve the safety, efficiency, and cost-effectiveness of complex medical care. Some of the medical home models that were developed in that period have been successful, whereas others have not.2–4 The current ASA-supported PSH Collaborative will likely demonstrate that some PSH models have a positive impact on patient safety, efficiency, and cost-effectiveness of perioperative care, whereas others do not. So far, the evidence is that most studies of the PSH are positive.5 Former U.S. Speaker of the House of Representatives Thomas P. (“Tip”) O’Neill, Jr. famously observed that “All politics is local.” That applies here, mutatis mutandis: all health care management is local. Anesthesiologists, hospital and health system administrators, payors, and other stakeholders will need to assess how findings from our Collaborative experience should be incorporated into their local practices, accounting for the specific requirements of their local environments.
A NEED FOR A PARADIGM SHIFT IN PRACTICE?
One admonition by Prielipp et al. is that there should be a paradigm shift in how anesthesiologists practice.1 The authors speculate that anesthesiologists, especially those already in practice, may not be sufficiently well trained to provide the full range of perioperative care. Their contention seems to imply that all anesthesiologists will have to be fully trained perioperative specialists to work within PSH models or risk having their practices become nothing more than a hospital commodity. That would be akin to proposing that every anesthesiologist in a large group practice must be able to care for children undergoing complex congenital heart procedures. That just is not the case. Most group practices recruit a subset of members who have specific pediatric cardiac anesthesiology training. These colleagues are tasked with caring for children undergoing complex procedures. Nearly all of us specialize within our practices or by limiting our practices. It is likely that groups will identify and hire a subset of members who have unique interest, training, and experience in perioperative care. Members with administrative talents will oversee the development of perioperative care pathways and supervise the teams responsible for delivering complex care to patients on those pathways.
Their contention also would suggest that currently practicing anesthesiologists are incapable of adapting to changing conditions, specifically that they are not able or willing to learn the skills required for broad-based perioperative care. Many anesthesiologists are highly knowledgeable about perioperative issues, probably more so than any other specialist. All anesthesiologists have options for learning to deliver broad-based perioperative care. Since the 2001 formation of the Council on the Continuous Professional Development of Anesthesiologists by the ASA and ABA, the ASA has dramatically increased its educational programs related to perioperative care issues.
A NEED FOR A PARADIGM SHIFT IN EDUCATION?
Prielipp et al. appear to believe that in the future the specialty will need fewer but more specialized anesthesiologists.1 They state that there will be a need for fewer anesthesiology graduates and training programs, presumably from the elimination of existing programs that they do not believe to be highly resourced (e.g., those with <$1 million of National Institutes of Health–funded research).
However, they do not speculate how the closure of anesthesiology residencies could worsen the existing misdistribution of U.S. anesthesiologists. Approximately two-thirds of graduates of residency and fellowship training work during their first 5 years in practice within the state or surrounding states in which they train.6 More than two-thirds of the programs that they include in their list of 35 programs that currently have >$1 million of annual National Institutes of Health research funding are located primarily in states along the East and West Coasts of the United States. In all likelihood, this geographic misdistribution would negatively impact the number of graduates who provide care throughout the great expanse of the country.
Prielipp et al.1 propose a 5-year curriculum in all of their anesthesiology training subgroups. This expansion from the current 4 to the proposed 5 years of training would add considerable unfunded fiscal burden onto surviving anesthesiology training programs, their institutions, and U.S. health care in general. When the ACGME proposed increasing out-of-operating-room experiences by 3 months in their 2006 draft anesthesiology program requirements, the vast majority of programs vigorously objected, citing the significant fiscal implications of this unfunded mandate. Imagine the clamor that would accompany a proposal to add a mandatory year of training to anesthesiology residencies. Indeed, the authors fail to explain who would pay for the expansion of training. They apparently presume that the fewer highly resourced training programs would produce fewer graduates. Is the argument that the total additional costs of expanded training would be absorbed by training fewer anesthesiology residents?
We are in complete agreement with Prielipp et al.1 that any changes to the practice of anesthesiology and the training of anesthesiology residents and fellows should be subject to broad, extensive, and vigorous discussion. This is precisely why ASA, ABA, and ACGME leaders have collaborated during the past 14 years with practicing anesthesiologists and academic anesthesiology leaders to thoughtfully develop the concept of the PSH and dramatically expand educational opportunities related to the full realm of perioperative care. This is also why our jointly authored dialogue appears in this issue of Anesthesia & Analgesia.7
Multiple groups composed of diverse representatives of anesthesiology, nursing, and surgical practices in the United States have reviewed how to best improve the care of patients across the continuum of perioperative care. The questions asked by the authors of the accompanying article are quite good but not novel. We agree that there is still much yet to learn about PSH models and how they might impact the future of the specialty.
The ASA-supported PSH Collaborative is one of many efforts that will help U.S. anesthesiologists, hospitals, health care systems, regulatory agencies, and payors understand the potential perioperative practices that can improve patient safety, efficiency, and cost-effectiveness. This will be driven, in part, by the increasingly constrained resources for U.S. health care. Although this current PSH Collaborative effort may not satisfy Prielipp et al.,1 it is being developed, tested, and assessed systemically and deliberately. Many U.S. anesthesiology groups, ranging from very large consortia to small rural practices, have implemented versions of PSH models in their local environments. They are now sharing their findings with colleagues throughout the country through publications and presentations at major anesthesiology meetings. In many instances, their findings have been positive and have generated positive responses in their local health care systems.
There is no burning platform for rapid change. There is only an imperative to pursue change, proactively and deliberately, “before we have to.”
Name: Mark A. Warner, MD.
Contribution: This author helped prepare the manuscript.
Attestation: Mark A. Warner approved the final manuscript.
Name: Jeffrey L. Apfelbaum, MD.
Contribution: This author helped prepare the manuscript.
Attestation: Jeffrey L. Apfelbaum approved the final manuscript.
This manuscript was handled by: Steven L. Shafer, MD.
1. Prielipp RC, Morell RC, Coursin DB, Brull SJ, Barker SJ, Rice MJ, Vender JS, Cohen NH. The future of anesthesiology: should the perioperative surgical home redefine us? Anesth Analg. 2015;120:1142–8
3. Jackson GL, Powers BJ, Chatterjee R, Bettger JP, Kemper AR, Hasselblad V, Dolor RJ, Irvine RJ, Heidenfelder BL, Kendrick AS, Gray R, Williams JW. The patient-centered medical home: a systematic review. Ann Int Med. 2013;58:169–78
4. Mosquera RA, Avritscher EBC, Samuels CL, Harris TS, Pedroza C, Evans P, Navarro F, Wootton SH, Pacheco S, Clifton G, Moody S, Fanzin L, Zupancic J, Tyson JE. Effect of an enhanced medical home on severe illness and cost of care among high-risk children with chronic illness. JAMA. 2014;312:2640–8
5. Kash BA, Zhang Y, Cline KM, Menser T, Miller TR. The Perioperative Surgical Home (PSH): a comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes. Milbank Q. 2014;92:796–821
7. Prielipp RC, Morell RC, Coursin DB, Brull SJ, Barker SJ, Rice MJ, Vender JS, Cohen NH, Warner MA, Apfelbaum JL. Dialogue on the future of anesthesiology. Anesth Analg. 2015;120:1152–4